Before Starting Service Forms

Schedule Request (to be completed and returned)

Insurance Information (to be completed and returned)

Prescription Request (to be completed and returned)

 

 

 

Forms for Starting Services

(once appointment has been scheduled)

Child History (to be completed and returned)

Consents (to be completed and returned)

Emergency Treatment Release (to be completed and returned)

Financial Agreement  (to be completed and returned)

Health Policy

Cancellation Policy

Privacy Notice

 

Developmental Screening Forms

 

Screening Consent and Child History (to be completed and returned)

Privacy Notice

Request Additional forms (to be completed and returned.  Please provide your child's date of birth and if full-term or premature) 

Lake Forest Pediatric Associates request form, may be completed by physician, but not necessary